Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Oradell during CMS and state inspections, most recent first.
Kitchen exhaust hood not kept in good repair. Surveyors observed gaps greater than about one-half inch where hood panels joined, along with a dented section that prevented the panels from fitting tightly together. The FSD acknowledged the gaps and stated flames or heat from the stove could rise into the hood and enter behind it, and later the RFSD and LNHA acknowledged the damaged and separated sections were not properly reassembled after cleaning.
Failure to Protect Resident Privacy and Dignity: During a resident council meeting, two RA staff entered without knocking, one resident was rushed to the meeting before washing their face, and residents reported staff often entered rooms without permission. During incontinence care, a resident said the privacy curtain did not fully cover the area, and the IPN proceeded with care with help from a male CNA.
Failure to Investigate and Document Resident Grievances: Residents raised concerns about loud and disruptive aides, poor night-shift CNA performance, communication problems, weekend staffing, and delayed call bell response affecting toileting and care. The concerns were discussed in resident council meetings, but they were not filed as grievances, no formal investigation or written resolution was documented, and staff confirmed residents had only received verbal responses that they were working on it.
Staffing was insufficient to meet resident needs for timely incontinence care and call bell response. Residents reported ongoing weekend staffing problems, poor communication, and staff not answering call lights, and one resident said a call bell went unanswered for more than 20 minutes overnight. Surveyors observed a resident with a call light on for 14 minutes and a soaked brief, and another resident with double briefs soaked with urine and feces up to the back. Record review also showed multiple residents lacked consistent toileting or incontinence documentation across several days.
Surveyors found multiple environmental cleanliness and maintenance issues in resident rooms and common areas, including dusty vents, debris on HVAC units, broken furniture, a nonworking towel dispenser, missing or damaged shower privacy curtains, a nonworking shower light, and residue on dining room surfaces. Staff, including the LNHA, DON, and MD, confirmed several of the findings, and the facility policy required a safe, clean, comfortable, and homelike environment.
Missing Written Bed-Hold Reserve Payment Information: The facility did not provide written bed-hold notices with reserve payment details to residents or RRs when residents were transferred out for hospital or acute care. Records for three residents showed transfers related to SOB/flu, vomiting with confusion, and a RR-requested hospital transfer, but the notices or letters either omitted the reserve payment amount or were not found in the chart. Staff interviews showed the AD, DON, BOM, and nursing staff had inconsistent understanding of the bed-hold process and who was responsible for providing the written information.
SNF ABNs for two residents were incomplete because the forms did not list the estimated dollar amount for PT, OT, and other noncovered services. The MDSC confirmed the dollar amount should be specified, and the LNHA, DON, and RNCS acknowledged the rates were missing from the forms.
A resident with PTSD and another resident with ESRD and dialysis needs had incomplete care plans. The PTSD diagnosis was not included in the care plan, and the dialysis resident’s repeated refusal of a to-go lunch for dialysis was not documented in the care plan, despite staff awareness of both issues and the facility policy requiring person-centered care plans to reflect psychosocial needs and refusals.
A resident with hemiplegia, diabetes, and psychosis had active orders for sertraline and quetiapine, and the CP noted the combination may increase fall risk after a recent fall and requested documentation of the risk versus benefit if therapy continued. Although the physician accepted the recommendation, the record had no psych, MD, or NP note documenting the required clinical review, and later provider notes continued the meds without addressing the CP's concern.
A resident with an unstageable PU, severe cognitive impairment, COPD, and DM2 was observed with an air mattress that was attached to the bed but not powered on and functioning. Staff confirmed the mattress was off, and the DON stated the nurse would notice if it was not working. The resident’s skin checks were also documented as showing no skin breakdown even though the facility’s wound timeline showed multiple existing wounds, and a wound treatment order lacked the wound site.
A resident with a PEG tube, dysphagia, and severe cognitive impairment received bolus TF while also eating by mouth, but the PEG site was observed unsecured with no dressing, no redness or drainage noted, and no documented order for site care or tube securing. The RN stated PEG sites should be cleaned and covered, yet the chart lacked PEG site treatment orders and the care plan did not include PEG site care or securing interventions.
Pain management orders were not properly clarified for two residents. One resident had a lidocaine patch order transcribed for the lower back, while staff and the physician stated it was also being used for the right knee without a corresponding PO in the record. Another resident had PRN acetaminophen and oxycodone-acetaminophen orders, but the PRN pain regimen was not clarified by pain level or sequencing, and the resident received the opioid analgesic multiple times for reported pain.
An LPN administered a resident's scheduled Trazodone dose late, with the eMAR showing the medication was overdue before it was given. The LPN acknowledged the dose was outside the expected one-hour window, and the facility policy stated medications are to be administered within one hour of the prescribed time unless otherwise specified.
An expired safety needle was found in a med room, and two residents' inhalation medication foil pouches were opened without dates on a med cart. An LPN acknowledged the expired item, and an RN stated the pouches should have been labeled when opened; the facility policy required medications and biologicals to be labeled according to accepted pharmaceutical practices.
Two Recreation Assistants were observed performing improper hand hygiene during lunch prep in the dining room. One washed hands for 20 seconds but turned off the faucet with a bare hand before drying, and the other washed for only 10 seconds. Both staff members described the correct handwashing process during interview, and the facility policy required at least 20 seconds of vigorous hand rubbing, drying with a disposable towel, and using the towel to turn off the faucet.
A resident at high risk for pressure ulcers developed an unstageable pressure injury on the right hip due to inadequate assessment and documentation by the facility's nursing staff. Despite the resident's severe cognitive impairment and high Braden scale score, the facility failed to document or address the skin condition effectively, leading to the progression of the wound. The facility did not notify the physician promptly or initiate a care plan, and discrepancies in documentation practices further contributed to the deficiency.
The facility failed to update its facility-wide assessment, leading to inadequate supplies such as linens and incontinence pads. Residents and CNAs reported shortages, impacting care. Management was unable to provide an updated assessment or plan to address these deficiencies.
The facility was found deficient in maintaining a clean and homelike environment. Observations included dust and debris on air vents, unclean shower rooms with debris on the floor, and a resident's room with dried substances and dust accumulation. Staff confirmed the lack of regular cleaning, and no documentation was available to verify maintenance of cleanliness.
The facility failed to administer medications as scheduled for a resident and two other residents. A resident did not receive Alprazolam for several days due to unavailability and lack of communication with the pharmacy. Two other residents reported receiving their medications late, affecting their treatment for dizziness and other conditions. The facility's records confirmed these delays, which were not documented as per policy.
A resident reported receiving only one shower per week, contrary to the scheduled two showers, impacting their dignity and quality of life. Discrepancies were found between the shower schedule and documentation, with staff providing conflicting information. The facility's policies emphasize maintaining residents' abilities in daily activities, but the failure to adhere to the schedule resulted in a deficiency.
A facility failed to prevent a potential medication interaction by administering sodium bicarbonate and ferrous sulfate simultaneously to a resident, despite known interaction risks. The resident, with a history of anemia and other conditions, received these medications together, potentially reducing the absorption of ferrous sulfate. The facility's policy emphasized timing to prevent interactions, but this was not adhered to, and previous recommendations to separate these medications were not applied.
A facility failed to ensure proper respiratory care for a resident with COPD, as oxygen therapy was not administered according to the physician's order or documented in the eTAR. The resident was observed receiving continuous oxygen, despite a PRN order for use when oxygen saturation levels fell below 92. The LPN confirmed the continuous use, influenced by the resident's family, and the DON was notified. A handwritten order was later provided, but it was not reflected in the electronic medical record, and the facility did not clarify the order as required by their policy.
The facility failed to provide sufficient nursing staff, leading to inadequate care for residents. A resident reported being left on the toilet for an extended period due to staffing shortages, and staff interviews confirmed that aides were overburdened, especially on weekends. The facility consistently failed to meet state-mandated staffing ratios, and despite being aware of the issue, management had not implemented effective solutions.
The facility failed to accurately post the Nursing Home Resident Care Staffing Report (NHRCSR) and resident census at the beginning of shifts on two occasions during a survey. On one occasion, the report was outdated due to an oversight by the weekend receptionist, and on another, there was a discrepancy in the census numbers. The SC, DON, and LNHA were informed of these issues, which violated the facility's policy.
The facility failed to properly store and label medications, as observed by a surveyor. Two medication carts contained vials of blood glucose testing strips without the date of opening, and the central supply stock room was found unlocked with expired medications present. The DON acknowledged the expired medications and removed them for disposal. The facility's policy requires locked storage and proper handling of expired medications, which was not followed.
The facility failed to offer and document pneumococcal and influenza vaccinations for four residents, including those with cognitive impairments. Despite policies requiring vaccine offers within five days of admission, documentation was missing or incomplete. Interviews with staff revealed inconsistencies in the vaccination process, with the current IP struggling to update records after the previous IP's leave.
A resident with severe cognitive impairment and multiple diagnoses was affected when the pharmacy sent Anagrelide 1 mg instead of the ordered Anastrozole 1 mg. Nursing staff documented administration of the correct medication, but pharmacy shipping records showed repeated deliveries of the incorrect drug. Nurses failed to verify the medication against the physician's order upon receipt, resulting in the wrong medication being available for administration.
Kitchen Exhaust Hood Not Kept in Good Repair
Penalty
Summary
The facility failed to maintain the kitchen exhaust hood system in good repair and free of structural defects. During a kitchen tour with the Food Services Director, the surveyor observed the stainless steel exhaust hood above the cooktop had two sections with gaps measuring greater than approximately one-half inch where the panels joined, and one hood section was significantly dented along the side so the adjoining sections did not fit tightly together. When interviewed, the Food Services Director acknowledged the gaps and stated he understood that flames or heat from the stove could rise into the hood and enter through the gaps into the area behind the hood. On follow-up observation, the gaps were still present and had not been repaired. The Food Services Director stated he had noted the concern and intended to repair the hood but had not yet done so, and the Regional Food Services Director stated he would order replacement hood sections because the damaged panel required replacement. The Licensed Nursing Home Administrator later acknowledged that the hood sections were not reassembled correctly after cleaning and that the gaps resulted when the hood sections were not put back properly.
Failure to Protect Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain resident privacy and dignity during a resident council meeting, during incontinence care, and during personal care. On 5/11/26, the resident council meeting was arranged for 10:30 AM in the 2nd floor small activity room, but the meeting did not begin as planned because only two residents were present at 10:50 AM. Two additional residents arrived later, and one resident stated they had not been aware the meeting would start at 10:30 AM and had been rushed to the meeting by staff before washing their face. During the meeting, two Recreation Aides entered the room without knocking, and one remained briefly in the room while handling personal items before leaving after the surveyor requested privacy. During the same resident council meeting, residents described repeated instances of staff entering rooms without knocking, including when doors were open and when residents were in their rooms. One resident stated that staff often entered without knocking and that this had happened to them as well. The Director of Recreation acknowledged that residents' dignity and privacy should have been respected. The facility's Resident Rights and Dignity policies stated that employees shall treat residents with kindness, respect, and dignity, that private space and property are respected at all times, and that staff are expected to knock and request permission before entering residents' rooms. On 5/12/26, during an incontinence round, a resident voiced concern that the privacy curtain in their room did not fully cover their area when the Infection Preventionist Nurse was about to check the resident's incontinence brief. The nurse acknowledged the concern and proceeded with incontinence care with assistance from a male CNA. The surveyor also observed that the metal part of the privacy curtain was not properly hooked. In addition, the report identified a deficiency involving Resident #12's personal care, noting that care was rendered after the surveyor's inquiry and that the resident had been rushed to the meeting before washing their face.
Failure to Investigate and Document Resident Grievances
Penalty
Summary
The facility failed to follow its Grievances/Complaints, Filing policy by not conducting formal investigations of resident grievances, not making prompt efforts to resolve those grievances to the residents’ satisfaction, and not providing written responses with rationale. The deficiency was identified through review of resident council meeting minutes and the grievance binder, which showed that concerns raised by residents about aides being loud and disruptive during the night shift, 11-7 CNAs not performing tasks efficiently, poor communication, weekend staffing issues, and care partners walking past rooms on their phones without assisting or answering call bells were discussed in resident council meetings but were not documented as grievances in the file provided. During the resident council meeting with the surveyor, residents stated that call bell response was affecting toileting and care, and one resident said concerns raised in prior meetings continued to be issues while facility management only responded verbally that they were working on it. The residents confirmed that no written resolution had been provided for their concerns. Review of the grievance binder for 2026 showed no documented evidence that the concerns from the resident council meetings on the earlier dates were investigated, resolved in writing, or filed as grievances. Interviews with the DSS, DR, DON, and LNHA showed that staff understood resident and family complaints were to be treated as grievances and investigated, but the DR stated he did not file the grievance because the DON was present during the resident council meeting. The DSS confirmed that the concerns discussed in resident council meetings should have been filed as grievances, and the DON acknowledged that there were no grievance filings or written resolutions for the concerns raised. The facility policy stated that grievances must be promptly addressed, responded to in writing with rationale, and documented with a written summary of the investigation.
Insufficient Nursing Staff and Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs for timely incontinence care and call bell response. Resident council minutes documented resident concerns that staffing on weekends remained a serious issue, that staff were not properly communicating, and that some care partners walked past rooms on their phones without assisting or answering call bells. During a resident council meeting, residents reported that delayed call bell response was affecting toileting and care, and one resident stated the facility said it was working on the issue. Record review showed multiple residents lacked consistent documentation of bladder incontinence or toileting care across several days in the 30-day lookback period. One resident was care planned for bladder incontinence, another for bladder and bowel incontinence, and another for an indwelling catheter. During a tour, a resident stated short staffing had been a concern for a while and that the most recent call bell had gone unanswered for more than 20 minutes overnight. A CNA also stated that staffing had been short almost every day and every shift, with worse staffing on weekends. Surveyors directly observed delayed response and unmet incontinence needs. One resident’s call light remained on for 14 minutes, and when the room was checked the resident’s brief was soaked with urine and smelled of urine. Another resident was found with double incontinence briefs soaked with urine and feces up to the back, and the CNA confirmed the resident did not appear to have been changed that morning. The facility’s LNHA and DON were notified of the findings, and the report states no additional information was provided.
Unsafe and Unclean Resident Areas and Common Spaces
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment in multiple resident-use areas and common spaces. During a tour of the 1st floor private dining room, surveyors observed a ceiling return air vent with dust accumulation and a baseboard heater/air conditioner unit with dry leaves and a can tab on top of the coils. In the 1 North nursing unit lounge, surveyors observed dust and dried leaves on the heater/air conditioner unit, a broken wall table, and a fish tank cabinet underneath with thick dust accumulation and torn papers. In the bathing room area on 1 North, the shower privacy curtain was dangling because of seven loose hooks and the towel dispenser was not working. In the 2 South bathing room area, shower #1 had no privacy curtain, shower #2 had a light that was not working, and shower #4 had a vent with blackish substances and dust accumulation. In the 2nd floor main dining area, surveyors observed an air vent ceiling cover with brownish residues, a chipped windowsill, peeling wood at the steam table area, and brownish substances on the bottom wall molding near the entrance door and in the kitchen area. In addition, surveyors observed two residents’ room areas with blackish, grayish, and dusty substances on the floor near and under the bed, and on ceiling vents and floor tiles near the air conditioning system. The facility’s LNHA, DON, Maintenance Director, and other staff confirmed several of the observations during the tour, and the facility policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Missing Written Bed-Hold Reserve Payment Information
Penalty
Summary
The facility failed to provide written information to residents or their Resident Representatives explaining the reserve bed payment policy when residents were transferred out of the facility. This deficiency was identified for 3 of 4 residents reviewed for the discharge process, including residents who were sent to the hospital or acute care and for whom the record did not show the required written bed-hold notice with reserve payment information. For one resident, the record showed diagnoses including osteoarthritis of the knee, a right artificial knee joint, and type 2 diabetes mellitus, with a BIMS score of 12 indicating moderate cognitive impairment. After an acute transfer to the hospital for shortness of breath and influenza, the chart and electronic record contained no bed-hold notification to the resident or RR and no information about bed-hold reserve payment. The resident stated they were not notified of bed hold in December when they went to the hospital, and the AD stated she had only verbally informed residents or RRs and did not provide a written form or reserve payment amount for this resident. For another resident, the record showed diagnoses including a right femur fracture and diffuse large B-cell lymphoma, with a BIMS score of 14 indicating intact cognition. The resident had two episodes of projectile vomiting, weakness, and confusion compared to baseline, and was transferred to the hospital. Although the NTACF notified the resident and RR about the hospital transfer, it did not include bed-hold reserve payment information, and there was no printed bed-hold notice in the chart. For a third resident, the record showed hemiplegia and hemiparesis following cerebral infarction and end stage renal disease. After transfer to the hospital per the RR’s request, the letter to the RR stated that every resident was entitled to a ten-day bed-hold privilege, but it did not include the bed-hold reserve payment amount. Staff interviews showed inconsistent understanding of who was responsible for providing the written bed-hold information and payment details.
SNF ABNs Missing Estimated Dollar Amounts
Penalty
Summary
The facility failed to issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 2 of 3 residents reviewed for beneficiary notifications. During record review, Resident #4 had a Medicare Part A skilled service start date of 12/21/26 and a last covered day of 1/30/26, after which the resident remained in the facility. The SNF ABN given to the resident representative stated that beginning 1/31/26 the resident would be responsible for paying out of pocket for PT and OT services that insurance would not cover, but the form did not include a specified estimated dollar amount for each service. The resident representative electronically signed the form on 1/28/26. Resident #11 had a Medicare Part A skilled service start date of 3/1/26 and a last covered day of 4/24/26, and the resident also remained in the facility. The SNF ABN provided to the resident representative stated that beginning 4/25/26 the resident would be responsible for paying out of pocket for PT, OT, and OTHER services that insurance would not cover, but the form again did not list a specified estimated amount for each service. The lead MDS coordinator confirmed responsibility for the ABNs and stated the dollar amount should be specified on the form. The LNHA, DON, and RNCS later confirmed the rates were missing from the forms.
Incomplete Care Plans for PTSD and Dialysis Meal Refusal
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 2 of 28 residents reviewed. One resident was admitted with diagnoses including PTSD, but the care plan initiated on 2/20/26 did not include PTSD. During interview, an LPN confirmed the resident had PTSD and acknowledged it was not included in the care plan. The MDS specialist also stated that PTSD was not specifically included in the resident’s care plan. The facility’s Comprehensive Person-Centered Policy stated that the comprehensive care plan is informed by a resident’s physical and psychosocial needs, including those related to past traumatic events, and that services outlined in the plan are trauma-informed. Another resident was admitted with ESRD and dependence on renal dialysis, with an order for hemodialysis on Tue, Thu, and Sat with an 11 AM pickup time. The resident stated that transportation usually picked them up around 10:30 AM and returned them around 5:30 PM, and that the facility usually did not give them food to take to dialysis, leaving them hungrier. An LPN stated the resident consistently refused a to-go lunch and that staff asked every time, but could not recall a time the resident accepted one. The resident’s care plan, initiated 3/9/26, did not document that the resident was refusing food from the facility to bring to dialysis, despite the facility policy stating that the care plan should include services not provided due to the resident exercising rights, including refusal of treatment.
Failure to Document Risk-Benefit Review for Combined Psychotropic Therapy
Penalty
Summary
The facility failed to ensure physician services met professional standards of practice for one resident by not obtaining and documenting a clinical evaluation of the risk versus benefit of continuing combined antidepressant and antipsychotic therapy after the consultant pharmacist identified an increased fall risk. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, and unspecified psychosis, and the quarterly MDS showed intact cognition with a BIMS score of 14 out of 15, extensive assistance with ADLs, a history of falls, and behaviors including paranoia, yelling, and derogatory or offensive language. The resident had active orders for quetiapine 75 mg in the evening for bipolar disorder and sertraline 100 mg in the evening for depression. The consultant pharmacist noted that sertraline used with Seroquel may increase the risk of falls and referenced a recent fall in March 2026, stating that if therapy continued, the risk versus benefit should be documented. Although the physician accepted the recommendation and a telephone order was documented, the record contained no psychiatric evaluation, physician progress note, or nurse practitioner note documenting an assessment of the risks and benefits of continuing sertraline and quetiapine after the recommendation. The most recent psychiatric evaluation in the record was dated before the pharmacist's recommendation, and later physician and NP notes stated medications were continued without addressing the recommendation or documenting the clinical rationale and risk-benefit analysis.
Air Mattress Not Functioning and Wound Documentation Inaccurate
Penalty
Summary
The facility failed to ensure an air mattress was on and functioning for a resident with an unstageable pressure ulcer and other skin issues. The resident had diagnoses including COPD and type 2 diabetes mellitus, and the quarterly MDS reflected severely impaired cognition with a BIMS score of 3 out of 15. On observation, the resident was lying in a low-to-the-ground bed with an air mattress machine attached to the bed that was not powered on and functioning, and this was observed again the next day. Staff interviews confirmed the mattress was not on, and the LPN/UM stated she would have to check whether it should be checked every shift. The DON stated the nurse would notice if it was not working. The facility also inaccurately documented the resident’s skin observation. The eMAR/eTAR included a weekly skin check order, and the skin observation forms documented that the resident had no skin breakdown on multiple dates. However, the facility’s own wound timeline showed the resident had an unstageable sacral/coccyx pressure ulcer, bilateral buttock MASD, and vascular wounds on both calves and the right heel during the same period. The LPN/UM reviewed the skin observation tool and confirmed it stated no skin breakdown, but did not explain why the form did not reflect the resident’s existing wounds. In addition, the resident’s wound treatment order did not specify the site of the wound. The May 2026 eMAR/eTAR included an order to apply Ponds cold cream, wash the wound with normal saline, apply Procardia cream to the periphery, and use xeroform and mepilex occlusive dressing, but the order did not identify the wound location. The DON stated that the order should have included the site, and later stated that the physician was contacted for clarification after surveyor inquiry. The facility policy stated that the physician will order pertinent wound treatments, including pressure reduction surfaces and wound care treatments, and that the nurse shall describe and document the location and characteristics of pressure sores.
PEG Tube Site Care and Care Plan Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services for a resident receiving enteral feedings through a PEG tube and failed to ensure the resident’s care plan reflected PEG tube site care. Resident #11 had diagnoses including acute respiratory failure with hypoxia, encounter for attention to gastrostomy, and dysphagia, and the MDS indicated severe cognitive impairment with a BIMS score of 6. The resident was eating by mouth with supervision and also received Jevity 1.5 bolus tube feedings at night. During observation, the resident was seen eating a pureed meal and thin liquids, and staff reported the resident ate meals above 65% and also received tube feedings. When the PEG site was later observed with the RN present, the tube site had no redness or drainage, no dressing was present, and the tube was hanging from the abdomen and not secured. The RN stated that PEG sites should be cleaned with saline and covered with slit gauze or a dry dressing, usually every shift, but acknowledged there was no order for treatment, no order to secure the tube, and no care plan intervention for PEG site care. Record review showed the care plan addressed nutrition by mouth and tube feeding, feeding tube complications, and risk for skin breakdown related to the G-tube site, but it did not include interventions for PEG site care or securing the tube. The physician orders included Jevity 1.5 bolus feeding at bedtime, but there was no order for PEG site care or securing the tube. The facility’s policy stated that enteral tube sites should be kept clean, protected from irritation and infection, cared for at least daily and as needed, and the gastrostomy tube should be anchored to the skin with tape or an anchor device.
Pain Medication Orders Not Clearly Defined or Properly Documented
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for two residents. For one resident, the physician’s order for a lidocaine patch was transcribed for the lower back, but staff also reported that the patch had been ordered for the right knee. During survey review, the LPN could not locate a physician’s order for the right knee application and stated she did not know why there was no order for that site. The physician later confirmed that he had ordered the lidocaine patch for the right knee, but the order was not present in the record at the time of the survey observation and interview. The resident involved was cognitively intact, had diagnoses including COPD, pulmonary hypertension, type 2 diabetes mellitus, and obstructive sleep apnea, and the record showed the resident received pain medication regularly. The progress notes documented complaints of bilateral lower extremity pain and lower back pain. The resident stated that after transfer from the hospital the lidocaine patch was ordered for the lower back, and that at another time the nurse administered the patch to the right knee when the resident had severe knee pain and the knees buckled. The resident also stated that only one patch was ordered and that it was used on different days for the lower back or the right knee. For the second resident, the record showed PRN pain medications were ordered, including acetaminophen for mild pain and oxycodone-acetaminophen every 6 hours PRN for pain. The resident was cognitively intact and had diagnoses including chronic kidney disease, COPD, pain in the left shoulder, absence of the left great toe, and pain in the right leg. Survey review found that the PRN pain orders were not clarified according to the appropriate pain level or sequencing. The oxycodone-acetaminophen was administered multiple times during the review period, and the resident stated that the PRN Percocet helped with left foot pain. Staff acknowledged that the resident’s PRN Percocet order was later updated to include an indication for moderate to severe pain, confirming that the original PRN pain regimen had not been clearly specified.
Late Administration of Scheduled Medication
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when a medication for Resident #31 was administered late. The resident had a physician's order for Trazodone HCl 50 mg tablet, 0.5 tablet by mouth once daily for depression, with the dose scheduled for 8:00 AM on 5/7/26. During observation at 9:31 AM, the surveyor saw the LPN preparing medications for Resident #31, and the Trazodone order was highlighted in red on the eMAR, indicating it was overdue. At 9:39 AM, the surveyor observed the LPN administer the Trazodone to Resident #31, and the Medication Administration Audit Report showed the medication was scheduled for 8:00 AM, administered at 9:39 AM, and documented at 9:54 AM. When interviewed at 10:00 AM, the LPN stated the expectation was to give a medication within one hour before or after the scheduled time and acknowledged the Trazodone was administered late. The facility's Administering Medications Policy stated medications are administered within one hour of their prescribed time unless otherwise specified.
Expired supply and undated inhalation medications found in med room and cart
Penalty
Summary
The facility failed to properly store and label medications and biologicals in 1 of 2 medication rooms and 1 of 4 medication carts inspected. During inspection of the 1st floor North medication room, a safety needle was found that had expired, and the LPN present acknowledged that it was expired. The report also identified that the facility's Medication Labeling and Storage Policy required medications and biologicals dispensed by the pharmacy to be labeled in accordance with applicable federal and state requirements and accepted pharmaceutical practices. During inspection of south med cart #3 on the second floor, the surveyor found Resident #143's Ipratropium Bromide and Albuterol Sulfate Inhalation Solution foil pouch opened with no date written on it, with 28 unit-dose vials remaining inside. The pouch stated that once removed from the protective foil pouch, the individual vials should be used within two weeks. The surveyor also found Resident #55's Budesonide Inhalation Suspension foil pouch opened with no date on it, with 1 ampule remaining inside. The pouch stated that once opened, the ampules should be used within 2 weeks. The RN stated the expectation was to label the items when opened and acknowledged that the foil pouches were not labeled with the date of opening.
Hand Hygiene Not Followed by Recreation Staff
Penalty
Summary
The facility failed to follow appropriate hand hygiene practices for 2 of 2 Recreation Assistants observed during lunch preparation in the 2nd floor dining room. One Recreation Assistant washed his hands for 20 seconds but turned off the faucet with a bare left hand before drying his hands with a clean paper towel. During interview, he stated hand washing should be performed for at least 20 seconds and that a clean paper towel should be used to turn off the faucet, but the surveyor did not observe him do so. The second Recreation Assistant was observed washing his hands for 10 seconds in the dining room. During interview, he stated hand washing should last at least 20 seconds or include singing the happy birthday song twice, and said the 20 seconds begins when soap is applied and ends when soap is rinsed off. The surveyor notified the LNHA, DON, and RNCS of the concerns, and the facility policy later reviewed stated hands should be rubbed vigorously for at least 20 seconds, rinsed, dried with a disposable towel, and the towel used to turn off the faucet.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care to prevent and manage pressure ulcers for a resident, leading to the development of an unstageable pressure injury on the right hip. The resident, who was at high risk for pressure ulcers due to severe cognitive impairment and other medical conditions, was not properly assessed or monitored for skin impairments. Despite having a Braden scale score indicating high risk, the facility did not document or address the resident's skin conditions effectively, resulting in the progression of a pressure injury to an unstageable wound with slough and serosanguineous drainage. The facility's nursing staff did not follow professional standards of practice in assessing and documenting the resident's skin condition. There was a lack of documentation regarding the initial identification and measurement of the right hip wound, and the facility failed to notify the physician promptly. The wound was only identified during routine wound rounds by a consultant, and there was no evidence of a care plan being initiated to address the pressure injury. The nursing staff also failed to follow the physician's advice to consult a wound doctor for the right hip pressure wound. Additionally, the facility's documentation practices were inadequate, with discrepancies in the records and late entries that did not accurately reflect the resident's condition. The RN/UM admitted to missing the initiation of a care plan for the pressure ulcer, and the DON acknowledged a knowledge deficit among the nursing staff in assessing and describing wounds. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention and management contributed to the deficiency.
Facility-Wide Assessment and Supply Shortages
Penalty
Summary
The facility failed to ensure that a facility-wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents. This deficiency was evidenced by the lack of adequate supplies, such as linens and incontinence pads, which were insufficient to meet the needs of the residents. During the survey, it was observed that the facility's par levels for supplies were not updated or aligned with the current census, leading to a shortage of essential items for resident care. Interviews with residents and staff revealed that the facility often ran short on necessary supplies. Residents reported that gowns and incontinence pads were sometimes unavailable when needed. Certified Nursing Aides (CNAs) confirmed these shortages, stating that the supplies they received were insufficient for the number of residents they were assigned to care for. The CNAs had to rely on leftover supplies from previous shifts or wait for deliveries, which impacted their ability to provide timely and adequate care. The facility's management, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were unable to provide an updated Facility Assessment (FA) that included the necessary par levels for supplies. Despite being aware of the supply issues, the management did not have a clear plan or documentation to address the deficiencies. The lack of an updated FA and the failure to adjust supply levels according to the resident census contributed to the ongoing supply shortages, affecting the quality of care provided to the residents.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several observations made by the surveyor. On the 2nd floor nursing units, a gray, dust-like substance was found adhering to air circulation vent covers in both the 2 North and 2 South units. The Housekeeping Supervisor and Director of Maintenance confirmed that the vents were not clean and should have been regularly maintained. Additionally, there was no documentation available to verify regular cleaning of these areas, indicating a lapse in housekeeping protocols. In the 2 South nursing unit's shower room, the surveyor observed vinyl gloves, debris, and a shampoo bottle on the floor, along with various equipment such as lifts and wheelchairs. The floor was dry, suggesting it had not been recently cleaned. A Licensed Practical Nurse confirmed that the floor was not clean and that items should not be left on the floor. Furthermore, a resident reported a stain on the shower room floor, which was cleaned by a nursing aide before the resident's shower. Resident #94's room was found to have dried brownish and whitish substances on the floor and nightstand, along with an accumulation of dust and debris around the heater and windowsill. The resident's representative confirmed that these conditions had persisted for days. The surveyor noted that the facility's Cleaning and Disinfection of Environmental Surfaces Policy was not being followed, as regular cleaning and disinfection were not documented or evident in the observed areas.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that a resident's medication was available and administered as scheduled, as well as failed to administer medications on time for two other residents. For Resident #66, the medication Alprazolam was not available and not administered for several days. Despite the resident being alert and having no immediate concerns, the medication was crucial for managing their anxiety and restlessness at night. The facility's records showed multiple instances where the medication was not dispensed, and there was a lack of communication with the pharmacy and physician to resolve the issue promptly. For Resident #87, there were concerns about not receiving morning medications at the scheduled time, which affected their management of dizziness. The resident reported receiving medications late on several occasions, which was confirmed by the facility's medication administration records. The records indicated that medications were administered outside the scheduled timeframe, and there was no documentation explaining the delays. Similarly, Resident #79 experienced delays in receiving both morning and evening medications. The resident reported late administration of medications on multiple occasions, and the facility's records corroborated these claims. The facility's policy required medications to be administered within one hour of the scheduled time, but this was not adhered to, and there was insufficient documentation to justify the delays.
Failure to Honor Resident's Shower Schedule and Preferences
Penalty
Summary
The facility failed to honor a resident's shower schedule and preferences, impacting their dignity and quality of life. Resident #52, who was alert, oriented, and independent with activities of daily living, reported receiving only one shower per week for the past couple of weeks, despite being scheduled for two showers weekly. The resident expressed dissatisfaction with the frequency of showers, indicating a preference for more frequent bathing. During the survey, discrepancies were found between the shower schedule and the actual documentation in the electronic medical record (EMR). The Registered Nurse/Unit Manager (RN/UM) and Certified Nurse Aides (CNAs) provided conflicting information about the shower schedule and documentation process. CNA #2, responsible for Resident #52, was unaware of the shower schedule binder and had not taken any residents for showers on the day of the survey. The EMR review revealed a lack of documentation for the resident receiving routine showers twice a week as scheduled. The facility's policies on Activities of Daily Living and Resident Rights emphasize the importance of providing appropriate care and services to maintain or improve residents' abilities to carry out daily activities, including hygiene. However, the failure to adhere to the shower schedule and document the care provided resulted in a deficiency in treating the resident with respect and dignity, as required by federal and state laws.
Failure to Prevent Medication Interaction
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by administering two potentially interacting medications simultaneously to a resident. During a medication pass observation, a Licensed Practical Nurse (LPN) administered sodium bicarbonate and ferrous sulfate to a resident at the same time, despite the potential for decreased absorption of ferrous sulfate when taken concurrently with sodium bicarbonate. The resident's medical records indicated a physician's order for ferrous sulfate to be taken three times daily for anemia, with instructions to avoid certain substances within two hours, and sodium bicarbonate to be taken twice daily. The surveyor noted that the electronic medical administration record (eMAR) and pharmacy notifications could alert staff to potential drug interactions, but this was not utilized effectively in this instance. The resident involved had a medical history that included hypercalcemia, chronic kidney disease stage 4, and anemia. A review of the facility's medication administration policy highlighted the importance of timing medications to prevent interactions, but this was not followed. Additionally, a Consultant Pharmacist (CP) report for another resident had previously recommended separating iron products from sodium bicarbonate by at least two hours, but this recommendation was not reflected in the CP admission review report for the resident in question. The deficiency was identified as a repeat issue, indicating ongoing non-compliance with professional standards of medication administration.
Failure to Ensure Proper Oxygen Therapy Documentation and Administration
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident receiving oxygen therapy, as per the physician's order and facility policy. The deficiency was identified through observations, interviews, and record reviews. A resident with severe cognitive impairment and a diagnosis of chronic obstructive pulmonary disease (COPD) was observed receiving oxygen therapy at 2 liters per minute (LPM) via nasal cannula, which was not properly documented in the electronic Treatment Administration Record (eTAR) for November and December 2024. The resident's care plan indicated a risk for respiratory impairment, and the physician's order specified oxygen use as needed (PRN) for oxygen saturation levels below 92, yet there was no documentation of such use. The Licensed Practical Nurse (LPN) confirmed that the resident was on continuous oxygen, contrary to the PRN order, and mentioned that the resident's family wanted the oxygen on all the time. The Director of Nursing (DON) was informed of the issue, and a handwritten physician order was provided after the surveyor's inquiry, indicating a change in oxygen delivery at different times of the day. However, this order was not reflected in the resident's electronic medical record, and the facility did not provide further documentation to clarify the order. The facility's Oxygen Administration Policy requires verification of a physician's order and documentation of the procedure, which was not adhered to in this case.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. A resident reported being left on the toilet for about half an hour due to a lack of available aides, and the resident council minutes confirmed a similar incident where the resident waited for assistance. The facility's staffing issues were particularly pronounced on weekends, with aides being spread too thin and unable to provide timely care. Interviews with staff revealed that the facility was consistently understaffed, especially on weekends, with aides having to care for more residents than the state-mandated ratios. The staffing coordinator acknowledged the challenges in maintaining adequate staffing levels, citing a loss of aides and difficulties in recruiting replacements. Despite efforts to call in additional staff, the facility did not offer bonuses or utilize agency staff to fill the gaps, leading to ongoing staffing shortages. The facility's staffing records for the two weeks prior to the survey showed consistent deficiencies in CNA staffing levels, failing to meet the required ratios on all day shifts. The facility's policy on providing sufficient and competent nursing staff was not adhered to, resulting in inadequate care for residents. The Director of Nursing and the Licensed Nursing Home Administrator were aware of the staffing issues but had not implemented effective solutions to address the deficiencies.
Inaccurate Staffing and Census Reporting
Penalty
Summary
The facility failed to ensure the accurate daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) and resident census at the beginning of the current shift for two out of six days during the annual re-certification survey. On 12/2/24, the surveyor observed that the NHRCSR posted at the front desk was dated 11/30/24, and there was no report for 12/2/24. The Staffing Coordinator (SC) acknowledged that the correct report was not posted due to an oversight by the weekend receptionist, who failed to update the report. The full-time receptionist corrected the error after the surveyors entered the facility. Additionally, on 12/5/24, there was a discrepancy in the census numbers on the NHRCSR, which did not match the Nursing Census Sheet and assignments for the two units. The SC was unable to explain the incorrect census, noting that corrections are typically made by the night shift or upon her arrival in the morning. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of these inaccuracies, which were in violation of the facility's policy requiring the posting of direct care daily staffing numbers for every shift.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications in accordance with its policy and standard clinical practice. During an inspection, a surveyor observed that two medication carts, labeled Cart 3 and Cart 4, contained vials of blood glucose testing strips that did not have the date of opening marked on them. The medication nurse confirmed that the vials should have been dated when opened. Additionally, the central supply stock room on the first floor was found unlocked, and within it, a metal cabinet containing stock medications was also unlocked. Expired medications, including bottles of Folic Acid and Aspirin, were found in the stock and were acknowledged by the Director of Nursing (DON) as expired and subsequently removed for disposal. The facility's policy on medication labeling and storage requires that all medications and biologicals be stored in locked compartments and that expired or discontinued medications be handled according to instructions from the dispensing pharmacy. The surveyor's findings indicated a failure to adhere to these policies, as evidenced by the unlocked storage areas and the presence of expired medications. The surveyor attempted to contact the facility's Consultant Pharmacist for further information but did not receive a response.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal and influenza vaccines to four residents, as well as document refusals or reasons for ineligibility. Resident #42, admitted with an intact cognitive status, had no documentation of influenza vaccination assessment or offer in their medical records. Interviews with the LPN and RN/UM revealed a lack of documentation and acknowledgment of missing vaccine information, despite the facility's policy to offer vaccines within five days of admission. Resident #66, with moderate cognitive impairment, had no documentation of being offered the flu vaccine for the 2024-2025 season until after surveyor inquiry. The DON confirmed that the previous Infection Preventionist had initiated flu vaccinations, but due to their leave, the current IP was trying to catch up, resulting in incomplete immunization records and delayed vaccine offers. Residents #94 and #197, both with severely impaired cognitive skills, had no documented evidence of being offered influenza or pneumococcal vaccines. The IPN, responsible for tracking and offering vaccines, confirmed the absence of consent forms and documentation in the medical records. The DON acknowledged the deficiency, stating that immunizations should be part of the admission process, with documentation of offers and refusals.
Incorrect Medication Delivered and Administered Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
The facility failed to provide the correct medication to a resident according to the physician's order when the pharmacy sent the wrong medication. A resident with a history of malignant neoplasm of the left breast, cerebral infarction, altered mental status, osteoarthritis, muscle weakness, and anxiety disorder, and who was totally dependent on staff for activities of daily living and had severely impaired cognition, was affected by this deficiency. The physician's order specified Anastrozole 1 mg tablet to be administered daily for post-breast cancer care, but the pharmacy erroneously sent Anagrelide 1 mg capsules instead. The medication administration records indicated that nursing staff documented the administration of Anastrozole as ordered, but shipping manifests from the pharmacy showed that Anagrelide was delivered to the facility on multiple occasions for the resident. The error was discovered when a registered nurse found Anagrelide in the medication cart and reported it to the previous DON. The nurse confirmed that there were no other residents prescribed Anagrelide at that time. The facility's investigation and pharmacy occurrence report confirmed that the pharmacy entered and shipped the wrong medication, and the nurses receiving the medication did not reconcile it against the resident's current medication orders as required by facility policy. Facility policy required licensed nurses to verify medications received from the pharmacy against the original medication order and ensure proper storage. However, the nurses who received and signed for the medication deliveries failed to perform this verification, resulting in the wrong medication being available for administration to the resident. This oversight led to the administration of a medication not ordered by the physician, as evidenced by the pharmacy shipping manifests and the facility's internal investigation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,547 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oradell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerson Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Careone At Valley | 1.4 mi | ★★★★★ | 1 | 0 |
| Dellridge Health & Rehabilitation Center | 1.7 mi | ★★★★★ | 22 | 0 |
| New Jersey Veterans Memorial Home At Paramus | 1.8 mi | ★★★★★ | 2 | 0 |
| Careone At Ridgewood Avenue | 2.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.